Truog Robert D, Robinson Walter M
Department of Anesthesiology, Harvard Medical School, Cambridge, MA, USA.
Crit Care Med. 2003 Sep;31(9):2391-6. doi: 10.1097/01.CCM.0000090869.19410.3C.
The "dead-donor rule" requires patients to be declared dead before the removal of life-sustaining organs for transplantation. The concept of brain death was developed, in part, to allow patients with devastating neurologic injury to be declared dead before the occurrence of cardiopulmonary arrest. Brain death is essential to current practices of organ retrieval because it legitimates organ removal from bodies that continue to have circulation and respiration, thereby avoiding ischemic injury to the organs. The concept of brain death has long been recognized, however, to be plagued with serious inconsistencies and contradictions. Indeed, the concept fails to correspond to any coherent biological or philosophical understanding of death. We review the evidence and arguments that expose these problems and present an alternative ethical framework to guide the procurement of transplantable organs. This alternative is based not on brain death and the dead-donor rule, but on the ethical principles of nonmaleficence (the duty not to harm, or primum non nocere) and respect for persons. We propose that individuals who desire to donate their organs and who are either neurologically devastated or imminently dying should be allowed to donate their organs, without first being declared dead. Advantages of this approach are that (unlike the dead-donor rule) it focuses on the most salient ethical issues at stake, and (unlike the concept of brain death) it avoids conceptual confusion and inconsistencies. Finally, we point out parallel developments, both domestically and abroad, that reflect both implicit and explicit support for our proposal.
“死亡供体规则”要求在移除维持生命的器官用于移植之前，患者必须被宣布死亡。脑死亡概念的提出，部分原因是为了让患有严重神经损伤的患者在心肺骤停发生之前就被宣布死亡。脑死亡对于当前的器官获取实践至关重要，因为它使从仍有循环和呼吸的身体中移除器官合法化，从而避免器官的缺血性损伤。然而，长期以来人们一直认识到脑死亡概念存在严重的不一致和矛盾之处。事实上，这一概念与任何关于死亡的连贯生物学或哲学理解都不相符。我们审视了揭示这些问题的证据和论据，并提出了一个替代的伦理框架来指导可移植器官的获取。这个替代方案并非基于脑死亡和死亡供体规则，而是基于不伤害原则（不伤害的义务，或首要的是不造成伤害）和尊重人的伦理原则。我们提议，那些希望捐赠器官且神经严重受损或濒临死亡的个人，应被允许捐赠其器官，而无需先被宣布死亡。这种方法的优点在于（与死亡供体规则不同）它关注了最关键的伦理问题，并且（与脑死亡概念不同）它避免了概念上的混乱和不一致。最后，我们指出国内外的一些平行发展情况，这些情况反映了对我们提议的隐性和显性支持。
